Roche Diagnostics UK and Ireland, Burgess Hill, UK.
Royal Brompton Hospital, Guy's and St Thomas' NHS Foundation Trust and Faculty of Lifesciences and Medicine, King's College London, London, UK.
ESC Heart Fail. 2023 Dec;10(6):3276-3286. doi: 10.1002/ehf2.14471. Epub 2023 Sep 11.
When relying on clinical assessment alone, an estimated 22% of acute heart failure (AHF) patients are missed, so clinical guidelines recommend the use of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for AHF diagnosis. Since publication of these guidelines, there has been poor uptake of NT-proBNP testing in part due to concerns over excessive false positive referrals resulting from the low specificity of a single 'rule-out' threshold of <300 pg/mL. Low specificity can be mitigated by the addition of age-specific 'rule-in' NT-proBNP thresholds.
A theoretical hybrid decision tree/semi-Markov model was developed, combining global trial and audit data to evaluate the cost-effectiveness of NT-proBNP testing using age-specific rule-in/rule-out (RI/RO) thresholds, compared with NT-proBNP RO only and with clinical decision alone (CDA). Cost-effectiveness was measured as the incremental cost per quality-adjusted life year (QALY) gained and incremental net health benefit. In the base case, using UK-specific inputs, NT-proBNP RI/RO was associated with both greater QALYs and lower costs than CDA. At a willingness-to-pay threshold of £20 000/QALY, NT-proBNP RO was also cost-effective compared with CDA [incremental cost-effectiveness ratio (ICER) of £8322/QALY], but not cost-effective vs. RI/RO (ICER of £64 518/QALY). Overall, NT-proBNP RI/RO was the most cost-effective strategy. Sensitivity and scenario analyses were undertaken; the conclusions were not impacted by plausible variations in parameters, and similar conclusions were obtained for the Netherlands and Spain.
An NT-proBNP strategy that combines an RO threshold with age-specific RI thresholds provides a cost-effective alternative to the currently recommended NT-proBNP RO only strategy, achieving greater diagnostic specificity with minimal reduction in sensitivity and thus reducing unnecessary echocardiograms and hospital admissions.
仅依靠临床评估，约有 22%的急性心力衰竭（AHF）患者被漏诊，因此临床指南建议使用氨基末端 B 型利钠肽原（NT-proBNP）进行 AHF 诊断。自这些指南发布以来，NT-proBNP 检测的应用率一直很低，部分原因是由于单一“排除”阈值<300pg/mL 的特异性较低，导致过度的假阳性转诊。通过添加特定年龄的“纳入”NT-proBNP 阈值，可以降低特异性低的问题。
本研究开发了一个理论上的混合决策树/半马尔可夫模型，结合全球试验和审计数据，评估了使用特定年龄的纳入/排除（RI/RO）阈值的 NT-proBNP 检测的成本效益，与 NT-proBNP 仅 RO 和临床决策（CDA）相比。成本效益以增量成本每质量调整生命年（QALY）和增量净健康效益来衡量。在基本情况下，使用英国特定的输入，NT-proBNP RI/RO 与 CDA 相比，不仅能获得更多的 QALYs，而且成本更低。在 20000 英镑/QALY 的意愿支付阈值下，NT-proBNP RO 与 CDA 相比也具有成本效益（增量成本效益比（ICER）为 8322 英镑/QALY），但与 RI/RO 相比则不具有成本效益（ICER 为 64518 英镑/QALY）。总的来说，NT-proBNP RI/RO 是最具成本效益的策略。进行了敏感性和情景分析；结论不受参数的合理变化的影响，对于荷兰和西班牙也得出了类似的结论。
一种将 RO 阈值与特定年龄的 RI 阈值相结合的 NT-proBNP 策略，为目前推荐的 NT-proBNP 仅 RO 策略提供了一种具有成本效益的替代方案，在最小化敏感性降低的情况下，实现了更高的诊断特异性，从而减少了不必要的超声心动图和住院治疗。
